Dr. Arthur Kavanaugh, rheumatologist and professor of medicine, University of California San Diego, took the time to answer MyRACentral's questions about pregnancy and RA - everything from getting pregnant to being pregnant to childbirth- and here are his answers. If you have additional questions, please leave them in the comments.
1. Does RA affect a woman’s ability to conceive?
Yes, data are a little bit difficult, because patients with RA are not all exactly the same as one another, but it does appear that impaired fertility is seen with RA. My sense is that it is one of those issues that is most severe in the most severely affected RA patients.
2. Does RA affect male fertility?
I do not think that’s really been studied very well. There are certain medications that we think are probably affecting sperm count, but we don’t usually think of fertility from the male end. The data are just not as good because there are too many variables. So, the answer is, I do not think so, but I don’t think there are great data that say that.
3. Most doctors seem to recommend going off DMARDs before trying to have a baby. In general, how long should you be off the medication before trying to conceive?
It really is much more dependent upon the type of treatment you are thinking of. In general, we usually try to get medications to a very low level in the body, but there are some medications we consider more seriously, such as methotrexate and leflunomide (Arava). For those people we say generally to wait two full periods from the time you last took a medication to the time you even begin to try to conceive, so it ends up being about three months. For leflunomide, we would ideally use a washout regimen (i.e., waiting until it’s out of your system or use a drug regimen to flush it out quickly. Contact your rheumatologist for more details).
4. Not taking any meds can mean a flare. Are there any RA meds are considered safer to take while trying to conceive or being pregnant?
Yes, the steroids are a category C, but there are is a long tradition of using those for RA. New TNF blockers are a category B, so we prefer not to use them, but there are certainly people who have gotten pregnant on them, and it may not be an unreasonable thing.
5. Certain RA meds can cause birth defects. What meds are these? What precautions should you take against becoming pregnant? How long should you be off these meds before it’s safe to try to have a baby?
Again, methotrexate and leflunomide are absolute no-nos, and the general recommendation for methotrexate is three months. However, leflunomide has an incredibly long half life, and we would ideally use a washout regimen.
6. Should pain management change when trying to get pregnant or when already pregnant?
Pain medicines, I think, are not necessarily the main go-to treatment for RA for a rheumatologist, because we like to control the immune response. But, they can be a useful adjunct. Patients can take regular pain meds, but strong pain meds we generally don’t like to use, that’s for sure [during pregnancy].
7. If you have trouble getting pregnant, should you try fertility treatments? How might those treatments affect RA?
Certainly. I think rheumatoid arthritis is distinct from some other autoimmune conditions, such as systemic lupus, in that we don’t think of pregnancy as worsening the condition. We mostly think of RA as getting better during pregnancy. There is not a tremendous amount of bad data with RA and fertility treatments.
8. Generally, people are advised to try getting pregnant the natural way for up to a year before consulting a fertility specialist. Given the likelihood of having a flare without your medication and the damage that can cause to your joints, should you explore fertility treatment options sooner than the suggested 12 months?
That’s really a more personal question and relates more to a patient’s age, for example. That’s a really personal decision, and obviously an important discussion we have with our patients all the time. But there is no easy answer to that one.
9. Can pregnancy lead to a remission of RA? If so, how long does it normally last?
It has always been thought that women would have a lessening of disease while pregnant. Not everyone improves, but I think the majority of people improve. However, it is not permanent and the activity of the disease often does come back.
We don’t know exactly why this is the case. A lot of hormonal changes have been looked at, but no single one is the reason people get better. We just don’t know.
10. Are there any differences in labor and childbirth with RA?
Not that I’m aware of, I think there is a chance of premature delivery and small birth weight, but that happens with steroids, we do know. But as far as just the birthing process itself, I do not think so.
11. Is there anything else you think is important to note about pregnancy and RA?
Pregnancy is obviously incredibly important and incredibly personal, and we have to make judgments individually with each patient. This topic comes up a lot. It’s difficult because there are so many variables, but we seem to be doing better with the newer therapies.
Published On: May 24, 2010